Decoding Medical Decision Making (MDM) for Psychiatric E/M Codes

The most common coding question in outpatient psychiatry is whether a visit is a 99213 or a 99214. The answer comes down to Medical Decision Making.

MDM is one of two methods for selecting an E/M level. The other is total time on the date of service. One thing to know up front: if you report an add-on psychotherapy code with the E/M, the time pathway is off the table. The E/M must be selected on MDM, because psychotherapy is the time-based service and the same minutes cannot support both.

The Structure

MDM measures the complexity of the encounter across three elements:

• The number and complexity of problems addressed

• The amount and complexity of data reviewed and analyzed

• The risk of complications, morbidity, or mortality from treatment

You need to meet or exceed the threshold in two of the three to support a given level.

Element 1: Number and Complexity of Problems

This element reflects the clinical significance of the conditions you evaluated or managed during the visit.

A diagnosis contributes only when it is actively addressed. A condition does not increase complexity because it appears on the problem list. What matters is whether you evaluated, monitored, or made management decisions about it during the encounter.

These do not increase problem complexity on their own:

• Listing a diagnosis as past medical history

• Documenting a history of depression or anxiety without assessment or management

• Repeating a diagnosis without evaluation or decision-making

• Carrying a diagnosis forward with no active plan

Low. Two or more self-limited or minor problems, one stable chronic psychiatric illness, or one acute uncomplicated psychiatric illness. Stable means symptoms are unchanged or improving compared to the prior visit, without exacerbation, progression, or treatment-related complications. Symptoms may still be present. The clinical course simply is not worsening.

Moderate. One or more chronic illnesses with exacerbation, progression, or treatment-related side effects. Two or more stable chronic psychiatric illnesses. One undiagnosed new psychiatric problem with uncertain prognosis. One acute psychiatric illness with systemic symptoms.

High. One or more chronic psychiatric illnesses with severe exacerbation or progression. One acute or chronic psychiatric illness posing a threat to life or bodily function.

Element 2: Amount and Complexity of Data

Data is organized into categories, and the level depends on how many categories you meet rather than how many items you list.

Category 1: Review of prior unique external notes. Ordering of each unique test. Review of results of each unique test. Assessment with an independent historian.

Category 2: Independent interpretation of a test.

Category 3: Discussion of management or test interpretation with an external provider.

Limited requires one category: any two items from Category 1, or an assessment with an independent historian.

Moderate requires one category: any three items from Category 1, or Category 2, or Category 3.

Extensive requires two categories.

Remember that data is external records, tests, independent interpretation, and outside providers.

Element 3: Risk of Complications

Risk reflects the potential for harm from your management decisions, not symptom severity on its own. Two patients with identical symptoms can carry different risk levels depending on what you decided to do.

Low. Minimal potential for harm, generally without prescription drug management. Psychoeducation, reassurance, or supportive counseling without medical management. Therapy-focused intervention without medication changes. Over-the-counter recommendations only. In psychiatric practice, low risk is uncommon whenever prescription medications are actively evaluated.

Moderate. Prescription drug management, meaning initiation, discontinuation, dose adjustment, or active monitoring of ongoing therapy. Management decisions significantly limited by social determinants of health. Ongoing monitoring for medication effects, adverse reactions, or treatment response requiring clinical judgment.

Prescription drug management supports moderate risk when the visit includes active clinical decision-making about the medication, even when nothing changes. Assessment of effectiveness, tolerability, adherence, or the need for monitoring all count. Simply listing or continuing a medication without evaluation may not.

High. Escalation of care including hospitalization, emergency referral, or crisis intervention. Intensive safety planning for credible suicide or violence risk. Initiation or management of high-risk medications requiring close monitoring, such as lithium or clozapine. Management of medication toxicity. Complex polypharmacy with significant interaction risk.

High risk may occur even without hospitalization, when management decisions carry substantial potential for serious harm.

99213 or 99214: Where the Decision Usually Lands

Here is the practical version.

Risk is moderate on most psychiatric medication visits, because prescription drug management with documented clinical reasoning meets the moderate threshold. That is one element.

You need a second, and it comes from either Problem or Data.

From Problem, you reach moderate with two or more stable chronic conditions actively managed, or one condition with exacerbation, progression, or treatment-related side effects.

From Data, you reach moderate with a discussion with an external provider, an independent interpretation of a test, or any three Category 1 items.

If neither happens, the visit is a 99213. One stable chronic illness, no external records or tests, a continued medication, and nothing else is low Problem, minimal Data, moderate Risk. That is one moderate element out of three.

This is the part worth sitting with. The question is not whether your patients are complex. It is whether a second element was met and documented. Providers who assume every medication visit is a 99214 and providers who default everything to 99213 are making the same mistake from opposite directions, which is deciding the level before checking the elements.

Documenting It

You do not need to write the word MDM anywhere. You need a note where a reviewer can locate all three elements.

Problem. Name every condition you addressed, with severity, stability, and any change since the last visit. Two conditions addressed should read as two conditions addressed, not as one diagnosis with a second mentioned in passing.

Data. Record what you reviewed, where it came from, and how it affected your thinking. "Records reviewed" tells a reviewer nothing. Name the source and the relevant finding. If you spoke with the patient's therapist or primary care provider, document the conversation and what you agreed on.

Risk. Document the medication decision, including the rationale, whether anything changed, and what you are monitoring. If you assessed safety, document what you found and what you did about it.

The Bottom Line

MDM is not complicated once the elements are separated out. The work in psychiatric practice frequently supports moderate complexity. Whether the note supports it is a different question, and that is the one that determines your code.

Want the reference tools that make this faster?

The Psychotherapy Documentation and Coding Handbook includes a checkoff tool for determining the E/M level from Problem, Data, and Risk, psychiatric practice examples for each level, and full note examples with the MDM breakdown shown for each one.

Get your copy

Crystal Stone, PMHNP-BC, FNP-BC, CPMA, CPC, and CPB of New Leaf Billing, Coding, and Auditing Solutions, LLC, conducted an independent content review of the Psychotherapy Documentation and Coding Handbook for general alignment with documentation and coding standards.

This content is intended as general educational information and does not constitute coding, billing, or legal advice. Coding requirements and payer policies vary by plan, state, and setting. Providers should verify requirements against current CPT, CMS, and payer-specific guidance, and should follow the documentation, supervision, and scope-of-practice requirements applicable to their licensure.